On April 2, the number of confirmed cases of coronavirus disease of 2019 (COVID-19) surpassed 1 million globally, with over 240,000 cases in the United States.1 Reports indicate that approximately 80% of those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, will not require hospitalization.2 Even so, it has become increasingly clear that infected patients may present in a number of ways, including neurologic symptoms that coincide with, or may precede, the hallmark pulmonary symptoms and fever. Pre-print data from hospitals in Wuhan, China found 36% of patients with COVID-19 had neurologic symptoms, with 5.9% of cases being complicated by stroke (median 10 days after symptom onset).5,6 Patients with COVID-19 experiencing stroke were reportedly older, had more cardiovascular comorbidities, and more severe pneumonia.
The need for optimal stroke care during this pandemic has become a growing concern among vascular neurologists and clinicians caring for patients with stroke. As such, the American Heart Association/American Stroke Association (AHA/ASA) Stroke Council leadership published in Stroke a temporary emergency guidance for stroke centers in the United States. This broad policy statement serves as interim guidance for the acute management of patients with stroke during this historic outbreak.3,4
Responding to a Code Stroke
Shortage of personal protective equipment (PPE) in the emergency department and on inpatient units may affect stroke teams responding to code stroke. In an ideal scenario, every code stroke patient would be treated as potentially infected and the responding team would don full PPE at the highest level. At medical centers where PPE supplies are limited, this may prove difficult, and teams should aim to minimize PPE use when possible. To that end, it is advisable to send the fewest team members possible to evaluate code stroke patients, and into rooms for follow up visits.
The use of telemedicine both within emergency departments and regionally can further help reduce PPE use, while allowing for reasonable stroke evaluation, avoiding unnecessary interfacility transfers, and reducing exposure risks for the stroke team.
It is important to note that patients with stroke may have an asymptomatic SARS-CoV-2 infection or may develop COVID-19 after admission and treatment for stroke. Given the propensity for patients with stroke to develop fevers due to other complications, such as aspiration pneumonia and urinary tract infection, COVID-19 should be ruled out posthaste.
The Stroke Council leadership advises the continued treatment of stroke patients where appropriate. This includes adherence to: all published guidelines regarding patient selection for therapy; treatment times (eg, door-to-needle and door-to-groin puncture); and post-recanalization monitoring. In the setting of a pandemic, full adherence to all guidelines may not be possible at all times in every locality. As such, the Council assures that adherence is a goal, not an expectation.
Due to prophylactic quarantine or direct illness, stroke teams may have to function with fewer members. This strain may be exacerbated by neurologists and other team members being reassigned to support the increasing demands associated with COVID-19. Teams should use their judgment, guided by local realities, and continue to try to treat as many acute stroke patients as possible.
It is important to remember that clinicians in the emergency department of some medical centers are trained to evaluate a code stroke and, with stroke team guidance, can administer intravenous thrombolysis or transfer patients for possible mechanical thrombectomy as needed. Some centers also have a nonstroke team staff available to monitor patients and arrange for post-treatment with recombinant tissue plasminogen activator or post-thrombectomy care.
Medical Center Changes
Medical centers, especially those in the most affected regions, are likely to require all intensive care beds for patients with critical level of COVID-19 as this outbreak progresses. Consequently, some centers may request neurointensive care unit beds be reallocated for these patients.
Hospitals and critical care administrators should allow for patients with large intracerebral hemorrhage, subarachnoid hemorrhage, or large ischemic strokes at risk for herniation to be monitored in an intensive care unit with appropriately trained personnel where and when feasible. Moreover, there is a lack of data supporting the need for 24-hour observation with rigid intervals for regular vital signs and neurologic assessments in stroke patients who are status-post thrombolysis or thrombectomy being cared for in an intensive care unit; for patients who are stable, it is feasible to continue observation in step-down or other units if an intensive care unit bed is needed.7
Physicians and other health care personnel should follow the most up-to-date and evolving guidelines regarding intubation, interventional procedures, and critical care for patients with stroke in setting of a pandemic. Appropriate intensive care of seriously ill patients with hemorrhagic stroke, some of whom may be young and have excellent long-term outcome predictions, should be maintained.
In an effort to protect staff, facilitate infectious disease evaluations, and conserve PPE, a number of hospitals have chosen to admit all patients who are COVID-19 positive and patients under investigation, regardless of other co-incident diseases, to specialized COVID-19 units. Staff on these units may not have adequate stroke care training; stroke medical directors and coordinators should provide guidance to regarding the management of acute ischemic and hemorrhagic stroke patients to staff who are unfamiliar.
Emergency Medical Services
Anecdotal reports indicate a decrease in stroke related admissions in some communities. This may, in theory, be the result of individuals avoiding emergency medical services for mild stroke or stroke mimics due to anxiety surrounding COVID-19. Stroke leaders should encourage all members of their community, through local media or public marketing, to seek emergency care if they are experiencing symptoms of acute stroke.
In a statement, the Stroke Council Leadership noted that while these recommendations have yet to undergo their traditional process of development and peer review, they “acknowledge the mounting concern regarding optimal stroke care during the COVID-19 pandemic among vascular neurologists and those clinicians who care for patients with stroke.” As such, they will continue to collect individual protocols and best practices for stroke care and issue updates to their guidance as the outbreak develops.
2. Lipsitch M, Swerdlow DL, Finelli L. Defining the Epidemiology of Covid-19: Studies Needed [published March 26, 2020] NEJM. doi:10.1056/NEJMp2002125
3. Temporary emergency guidance to US stroke centers During the COVID-19 pandemic on behalf of the AHA/ASA stroke council leadership [published online April 1, 2020]. Stroke. doi:10.1161/STROKEAHA.120.030023
4. Interim guidance issued on stroke care during COVID-19 pandemic [press release]. Dallas, Texas: American Heart Association. https://newsroom.heart.org/news/interim-guidance-issued-on-stroke-care-during-covid-19-pandemic. Published April 2, 2020. Accessed April 2, 2020.
5. Mao L, Wang M, Chen S, et al. Neurological manifestations of hospitalized patients with COVID-19 in Wuhan, China: a retrospective case series study [published online February 25, 2020]. medRxiv. doi:10.1101/2020.02.22.20026500
6. Li Y, Wang M, Zhou Y, et al. Acute cerebrovascular disease following COVID-19: A single center, retrospective, observational study [published March 3, 2020]. doi:10.2139/ssrn.3550025
7. Faigle R, Butler J, Carhuapoma JR, Johnson B, Zink EK, Shakes T, et al. Safety trial of low-intensity monitoring after thrombolysis: optimal post tpa-IV monitoring in ischemic stroke (OPTIMIST) [published online May 5, 2019]. The Neurohospitalist. doi:10.1177/1941874419845229